EMS DocumentationEMS DocumentationEMS DocumentationEMS DocumentationPresence Regional EMS SystemPresence Regional EMS System

May 2015May 2015

Topics

• Functions of documentation• Components of the written report• Documentation of special situations

– Refusals– Cardiac Arrest– Termination of Resuscitation– Triple Zero– Field Death Declaration

• Record maintenance requirements

Introduction• The responsibilities of the EMT go

beyond the assessment, management, and transport of a patient to the hospital

• The EMT must also be able to prepare a patient care report, to document what was completed in the prehospital setting, should it need to be reviewed at a later time

Why do we document?Illinois Department of Public Health

Rules and RegulationsSection 515.350  Data Collection and

Submission

a) A run report shall be completed by each vehicle service provider for every emergency pre-hospital or inter-hospital transport and for refusal of care.

 1) One copy shall be left with the receiving

hospital emergency department, trauma center or health care facility before leaving this facility.

Why do we document?• A prehospital care report (PCR)

has several important functions:– Continuity of care– Legal documentation– Education– Administrative– Research– Evaluation and quality improvement

Why do we document?• Medical uses

• Helps to ensure continuity of care once the patient is delivered to the emergency department

• Legal uses• Although not the most important reason,

one of the very important reasons for documentation is that your record may be used in legal proceedings

Remember..... Prehospital Care Reports are

legal documents therefore they must be kept

confidential!!

Why do we document?• Education and Research• Can be used by researchers to

demonstrate the applicability of certain medical interventions

Why do we document?• Administrative uses

• Becomes a part of the permanent medical records maintained at the hospital for the patient

• It will be used in preparing bills and in submitting records to insurance companies.

Why do we document?• Quality Improvement

• Reviews of documentation are an integral part of the quality improvement process. Remedial and continued education courses for EMS in the system may be based upon needs revealed by call documentation.

Prehospital Care Report(PCR)

• Information provided on the PCR should give a clear and accurate picture of what occurred in the prehospital environment

• There are two basic rules to follow:• “If it wasn’t written down, it wasn’t

done.”• “If it wasn’t done, don’t write it down.”

Prehospital Care Report(PCR)

• General completion guidelines– Completely fill out form in its entirety– Use proper spelling and sentence structure– Use only approved medical abbreviations

Paper Reports• Use black ink• Correct errors in an accepted

manner• Check spelling • Read report before filing

Computer Report• Use spell check function• Check for automatic “drop downs”• Read report before filing

Problems with Spell-check

• “ patient is warm, oink and dry”– Should have been PINK

• “Contacted the corner”– Should have been Coroner

• “patient has tow lacerations”– Should have been two

Essential Components of Documentation

Illinois Department of Public Health Rules and Regulations

Section 515.Appendix E Minimum Prescribed Data Elements • General information• Response time information• Patient information• Patient assessment• Patient treatment

Essential Components of Documentation

• Chief complaint• History of present illness/injury• SAMPLE history• Physical exam findings• Initial and repeat vital signs• Interventions• Patient response to interventions

Methods for PCR Charting

– SOAPE•Subjective•Objective•Assessment•Plan•Evaluation

– CHART•Chief complaint

•History•Assessment•Rx–treatment•Transport

Documentation Tips• Scene Size-Up

– MOI• Position of patient• Approx. speed of vehicle• Location and extent of damage to car• Airbags deployed, seatbelt usage• Distance of fall, surface landed on• Helmet or no helmet

– Any clues pertinent to patient condition (examples: environment hot or cold, pill bottles, alcohol containers, odors.)

Documentation Tips• SAMPLE History to include:

– Signs and Symptoms/ History of present illness to include OPQRST

– Allergies– Medications– Past Medical History– Last Oral Intake– Events

Documentation Tips• Medications: (document for each dose)

– Name of medication– Route– Dose– Time given– Patient response to medication

**this includes oxygen**

Documentation Tips• Complete all checkboxes

– Make sure checkbox information matches written documentation

– If doing computer charting…. Beware of automatically populated fields

Documentation Tips• Splinting or Spinal Immobilization

– Chart PMS before AND after application

– Chart WHAT equipment you used to splint or immobilize a patient

Documentation Tips• Ongoing Assessment to include:

– Repeat vital signs• Every 5 minutes on unstable patients• Every 15 minutes on stable patients

– Response to interventions– Any changes in patient status

RefusalsRefusals

• The PREMSS refusal form has been devised The PREMSS refusal form has been devised to allow for better documentation of refusal to allow for better documentation of refusal of treatment and/or transport of a patient.of treatment and/or transport of a patient.

• In most cases only the refusal form will In most cases only the refusal form will need to be completed however there are need to be completed however there are situations when a full patient care report situations when a full patient care report should be completed in addition to the should be completed in addition to the refusal form.refusal form.

Refusal of CareRefusal of Care

• Patients have a Patients have a rightright to refuse to refuse treatment and transport to the treatment and transport to the hospital.hospital.

• Must meet certain criteria.Must meet certain criteria.• Documentation protects EMS Documentation protects EMS

from liability issues. from liability issues.

Duty to ActDuty to Act

• EMS has a EMS has a Duty to Act/Duty to Duty to Act/Duty to RespondRespond to calls to EMS for help: to calls to EMS for help:– 911 calls911 calls– Direct callsDirect calls

Public Assist CallsPublic Assist Calls

• Patient known in the communityPatient known in the community• Assess before moving:Assess before moving:

– A-B-CA-B-C– Quick head to toe assessmentQuick head to toe assessment– Areas of painAreas of pain– Anything different today from the pastAnything different today from the past– If only lift help, document as a refusalIf only lift help, document as a refusal

Review of Refusal Review of Refusal CriteriaCriteria

• Refusal of treatment/transport Refusal of treatment/transport should be initiated by the patient.should be initiated by the patient.

• At At NONO time should any EMS time should any EMS provider suggest or initiate a provider suggest or initiate a patient refusal.patient refusal.

• Upon refusal of treatment and/or Upon refusal of treatment and/or transport, the EMS provider should transport, the EMS provider should evaluate the patient.evaluate the patient.

Evaluation - Mental Evaluation - Mental StatusStatus

• Is the patient alert and oriented to Is the patient alert and oriented to person, place, time and event?person, place, time and event?

• Is the patient free of the influence Is the patient free of the influence of drugs or alcohol?of drugs or alcohol?

Evaluation - Vital SignsEvaluation - Vital Signs

• Evaluate airway, breathing and Evaluate airway, breathing and circulation.circulation.

• A complete set of vital signs should be A complete set of vital signs should be obtained.obtained.

• If patient refuses to have vital signs taken, If patient refuses to have vital signs taken, the EMS provider should use the EMS provider should use

a visual and verbal assessment a visual and verbal assessment to determine if vital signs to determine if vital signs are altered.are altered.

Evaluation - MOI / NOIEvaluation - MOI / NOI

• Is the scene free of significant Is the scene free of significant mechanism of injury?mechanism of injury?

• Does the patient have a life-threatening Does the patient have a life-threatening chief complaint or evidence of chief complaint or evidence of significant signs and/or symptoms?significant signs and/or symptoms?

• Is the patient free of “pertinent” Is the patient free of “pertinent” medical history?medical history?

Evaluation - Evaluation - CompetenceCompetence

– Is the patient Is the patient ≥≥ 18 years of age? 18 years of age?– If the patient is not the If the patient is not the

appropriate age:appropriate age:•Does the patient proof of Does the patient proof of

emancipation?emancipation?•Is accompanied by parent or legal Is accompanied by parent or legal

guardian?guardian?

Review of Refusal Review of Refusal CriteriaCriteria

• Explain possible risks and complications Explain possible risks and complications that may occur if treatment and/or that may occur if treatment and/or transport are not provided.transport are not provided.

• This may include This may include “death or reduction in “death or reduction in quality of life” quality of life” if the patient’s condition if the patient’s condition is considered life threatening by the is considered life threatening by the EMS provider or Medical Control.EMS provider or Medical Control.

• If EMS feels uncomfortable with If EMS feels uncomfortable with the patient refusing the patient refusing treatment/transport treatment/transport

• Use a reasonable amount of Use a reasonable amount of persuasion to try to get the persuasion to try to get the patient to consent to patient to consent to treatment/transport.treatment/transport.

Refusal Form Refusal Form DocumentationDocumentation

• Complete the PREMSS Refusal form by Complete the PREMSS Refusal form by answering all questions in the upper answering all questions in the upper portion of the form. portion of the form.

• Document scene and assessment Document scene and assessment findings in the space labeled findings in the space labeled “Notes/Comments”.“Notes/Comments”.

• Document vital signs in the space Document vital signs in the space provided.provided.

Medical ControlMedical Control

• Medical Control must be contacted Medical Control must be contacted when:when:– Any question in the upper portion of Any question in the upper portion of

the refusal form has been answered the refusal form has been answered “NO”“NO”

– If a patient refuses transport after EMS If a patient refuses transport after EMS treatment has been initiatedtreatment has been initiated

– All AMA refusalsAll AMA refusals

• When Medical Control is When Medical Control is contacted, check the box next to contacted, check the box next to the hospital contacted and print the hospital contacted and print the physician’s name on the line the physician’s name on the line indicated.indicated.

SignaturesSignatures

• Several signatures must be Several signatures must be obtained on the refusal formobtained on the refusal form

• The EMS provider should read The EMS provider should read aloud the release statement to aloud the release statement to ensure that the patient ensure that the patient understands what he/she is understands what he/she is signingsigning

Patient SignaturePatient Signature

• The patient’s name is to be printed in the The patient’s name is to be printed in the release statement in the space provided.release statement in the space provided.

• The patient (or parent/legal guardian) The patient (or parent/legal guardian) should sign on the line indicated.should sign on the line indicated.

• If the patient refuses to sign the form, If the patient refuses to sign the form, the reason must be documented on the the reason must be documented on the refusal form.refusal form.

• The patient must also initial a reason for The patient must also initial a reason for refusal in the space provided on the formrefusal in the space provided on the form

Against Medical AdviceAgainst Medical Advice

• If the EMS provider and/or Medical If the EMS provider and/or Medical Control do not agree to the Control do not agree to the patient’s refusal of treatment patient’s refusal of treatment and/or transport, and/or transport, the patient may the patient may still choose to refuse AGAINST still choose to refuse AGAINST MEDICAL ADVICE (AMA) MEDICAL ADVICE (AMA) provided provided that the patient is not a danger to that the patient is not a danger to himself or others. himself or others.

EMS Provider SignatureEMS Provider Signature

• The EMS provider in charge must sign The EMS provider in charge must sign on the line indicated at the bottom of on the line indicated at the bottom of the refusal form.the refusal form.

• The EMS provider must also indicate The EMS provider must also indicate with whom the patient was left.with whom the patient was left.

• If the patient is turned over to law If the patient is turned over to law enforcement, the accepting officer enforcement, the accepting officer must sign the form and include his/her must sign the form and include his/her badge number.badge number.

Witness SignatureWitness Signature

• A witness should also sign on the line A witness should also sign on the line indicated. indicated.

• Potential witnesses include any of the Potential witnesses include any of the following persons present at the time the following persons present at the time the patient signs the refusal form:patient signs the refusal form:

– Family members/friendsFamily members/friends– Law enforcement officialsLaw enforcement officials– Fire department personnelFire department personnel– BystandersBystanders– Other EMS providers (it is recommended that this Other EMS providers (it is recommended that this

be a last resort as a witness)be a last resort as a witness)

Revised PREMSS Refusal Revised PREMSS Refusal FormForm

• The revised form The revised form allows the EMS allows the EMS provider to provider to document all document all components of a components of a patient refusal using patient refusal using only one form in only one form in most cases.most cases.

• There are There are situations that situations that still require a still require a complete patient complete patient care report in care report in addition to the addition to the refusal form.refusal form.

Revised PREMSS Revised PREMSS Refusal FormRefusal Form

• A complete patient care report A complete patient care report should be completed in addition to should be completed in addition to the PREMSS refusal form when:the PREMSS refusal form when:– Any question in the upper portion of Any question in the upper portion of

the form is answered “NO”.the form is answered “NO”.– Medical Control has been contacted for Medical Control has been contacted for

any reason.any reason.– Any EMS treatment has been provided.Any EMS treatment has been provided.

AbandonmentAbandonment

• Failure to complete Refusal Failure to complete Refusal PaperworkPaperwork

• Failure to communicate with Failure to communicate with Medical Control when appropriate Medical Control when appropriate

• Constitutes abandonment.Constitutes abandonment.

Quality Improvement• A copy of all cardiac arrest PCR’s

should be sent to the EMS office (preferably within 24-48 hours)

• A copy of all BLS PCR’s with administration of medications (nitro, ASA, albuterol)

• Any PCR’s requested by the EMS office for random chart reviews

Cardiac Arrest Documentation

• CPR prior to EMS arrival• BLS AED attached• Initial Rhythm identified – strips

attached (PEA is not a rhythm)• Strips match treatment given• Treatment follows protocols• Airway secured – documentation of

successful airway (BLS and ALS)

• Vascular access• Transport/Termination of

Resuscitation• Status of patient on arrival at

hospital• Patient turn over to next level of

care

Termination of Termination of Resuscitation Resuscitation ALSALS

• Resuscitation may be halted without a Do Not Resuscitation may be halted without a Do Not Resuscitate order if:Resuscitate order if:– Patient is Patient is found in asystole/PEAfound in asystole/PEA– Unwitnessed arrest with no bystander CPR before Unwitnessed arrest with no bystander CPR before

arrival of EMSarrival of EMS– Patient remains in asystole/PEA despite the Patient remains in asystole/PEA despite the

treatment of the Asystole/PEA protocoltreatment of the Asystole/PEA protocol• CPRCPR• Airway securedAirway secured• Vascular accessVascular access• Epinephrine 1 mgEpinephrine 1 mg

Termination of Termination of ResuscitationResuscitation

• In order to Terminate Resuscitative In order to Terminate Resuscitative efforts for the previous criteriaefforts for the previous criteria– EMS must call medical control for EMS must call medical control for

permission to terminate resuscitationpermission to terminate resuscitation– The family must be in agreement with The family must be in agreement with

the terminationthe termination– EMS must call the local coronerEMS must call the local coroner

““Before the wheels Before the wheels roll.”roll.”

• The decision to terminate resuscitation The decision to terminate resuscitation must be made before the wheels of the must be made before the wheels of the ambulance roll to transport a patient to ambulance roll to transport a patient to the hospital.the hospital.

• No way to “register” a dead person.No way to “register” a dead person.

What if?What if?

• Patient is elderly or has significant Patient is elderly or has significant medical historymedical history

• Family unable to produce DNRFamily unable to produce DNR• Patient does not meet Triple Zero Patient does not meet Triple Zero

criteriacriteria• Family states patient did not want Family states patient did not want

resuscitationresuscitation• Now what? Now what? Contact Medical ControlContact Medical Control

Triple ZeroTriple Zero

• A patient who is not viable and for A patient who is not viable and for whom resuscitation efforts would whom resuscitation efforts would be fruitlessbe fruitless– UnconsciousUnconscious– No pulseNo pulse– No respirationNo respiration

Triple Zero Signs of Long Triple Zero Signs of Long Term DeathTerm Death

• The patient must exhibit one or more of The patient must exhibit one or more of the following signsthe following signs– Rigor mortis – stiffness of the limbsRigor mortis – stiffness of the limbs– Lividity – pooling of blood in dependent parts of the Lividity – pooling of blood in dependent parts of the

bodybody– DecompositionDecomposition– MummificationMummification– DecapitationDecapitation– No resuscitative efforts for at least 20 minutesNo resuscitative efforts for at least 20 minutes– No palpable pulses.No palpable pulses.– Asystole in 3 chest leads/Asystole in 3 chest leads/No shock indicated on AEDNo shock indicated on AED

• Contact Medical Control Contact Medical Control – Document:Document:

• FindingsFindings• Time Triple Zero confirmedTime Triple Zero confirmed• Hospital calledHospital called• Physician on the radioPhysician on the radio• Coroner contacted Coroner contacted • Patient hand offPatient hand off

– The “confirmation of TripleThe “confirmation of TripleZero assessment” does not constituteZero assessment” does not constitutea pronouncement of death.a pronouncement of death.

Remember toRemember to

• Call the local coronerCall the local coroner

If any doubt exists, If any doubt exists, resuscitateresuscitate

Especially if:Especially if:

suspected hypothermiasuspected hypothermia

drowning/near drowningdrowning/near drowning

uncertain down timeuncertain down time

Field Death Declaration• Chance of survival from traumatic Chance of survival from traumatic

cardiac arrest at the scene is cardiac arrest at the scene is minimalminimal

• Must make the best use of time, Must make the best use of time, personnel and resourcespersonnel and resources

• Protocol approved for all levels of Protocol approved for all levels of EMS providers (FR-D, Basic, EMS providers (FR-D, Basic, Intermediate, Paramedic)Intermediate, Paramedic)

FDD Criteria• Significant mechanism of injury• Over the age of 14• Pulseless and not breathing on EMS

arrival• Not treatable EKG rhythm (No shock

indicated on AED)• No signs of life

• Contact Medical Control Contact Medical Control – Document:Document:

• FindingsFindings• Time Field Death Declaration confirmedTime Field Death Declaration confirmed• Hospital calledHospital called• Physician on the radioPhysician on the radio• Coroner contacted Coroner contacted • Patient hand offPatient hand off

– The “confirmation of FDDThe “confirmation of FDDassessment” does not constituteassessment” does not constitutea pronouncement of death.a pronouncement of death.

Record Maintenance

• Handwritten reports (narrative and “bubblesheet”) – PREMSS Non-transport– Must use NEMSIS compliant PCR’s– One copy each to the receiving facility– One copy each to the EMS agency– One copy each sent to the EMS office

• Copies should be sent to the EMS office on a monthly basis

Record Maintenance• Computerized reports

– All software used for computerized documentation must be NEMSIS compliant

– Data must be submitted to IDPH quarterly for all transport agencies

– One copy of report should be left at the receiving facility at the time of the call

Review• Answer the following questions as a

group.• If doing this CE individually, please e-

mail your answers to:shelley.peelman@provena.org

• Use “May 2015 CE” in subject box.• You will receive an e-mail confirmation.

Print this confirmation for your records, and document the CE in your PREMSS CE record book.

Review1. List and describe the 6 functions

of prehospital documentation.

2. True or False? A prehospital care report does not become a part of the patient’s permanent record therefore it does not need to be left at the receiving facility.

Review3. True or False? Prehospital care

reports are considered confidential and are covered under HIPAA regulations.

4. True or False? Prehospital care reports are sent to the EMS office annually.

Review5. Name 4 essential components of

prehospital documentation.

6. What needs to be documented in a Refusal of Care situation?

7. When do you need to call Medical control in a Refusal of Care situation?

8. What needs to be documented on a cardiac arrest?

9. ALS: When can resuscitation be terminated?

• 10. What needs to be documented for a Triple Zero call?

• 11 What needs to be documented for a Field Death Declaration?

• 11. What is a drawback of using spell check with computerized documents?